Sample Benefits Insurance Notification Letter - PDF

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Sample Benefits Insurance Notification Letter - PDF Powered By Docstoc
					                                            604 W. Warner Road, Ste. B-6~ Chandler, AZ 85225
                                            6140 S. Kings Ranch Road~ Gold Canyon, AZ 85218
                                      Complete Medical & Surgical Eye Care for All Ages
                                               Thank you for choosing our office.
PATIENT INFORMATION:

Last Name: _______________________________ First _____________________________ MI ________

Birth date: _____________ Age: ________ Sex: _____ SSN: _____________________________

Address: __________________________________ City: ______________ State: _____ Zip: __________

Home Phone: _______________ Work Phone: _______________ Cell Phone: _____________________

E-mail address: __________________________

Patient Status: ( )-Married ( )-Single           ( )-Divorced ( )-Separated ( )-Widowed ( )-Other

Primary Care Physician: _________________________ Telephone: ____________________

Referred by: ___________________________________ Telephone: ____________________

SPOUSE/PARENT GUARDIAN INFORMATION:

Name: __________________________________ Home Phone: ___________ Work Phone: ____________

Address: ______________________ City: ___________ State: _____ Zip: _____ SSN: _______________

In Case of Emergency Contact (Name of person not living with you):
Name: __________________________________ Home Phone: ___________ Work Phone: ____________

AUTHORIZATION:
Do you authorize this office to discuss your medical care or account information with any other person other than yourself?
_____ YES        _____ NO
If yes, please list name(s) of person(s) and contact phone numbers.
Name: ___________________________________________ Home Phone: _________________________
Name: ___________________________________________ Home Phone: _________________________

PRIMARY INSURANCE INFORMATION:

Primary Insurance: __________________________________________ Effective Date: _______________
Subscriber ID: ______________________________________ Group No: __________________________
Policyholder’s Name: __________________________________ DOB: ________ SSN: ______________
Relation to Insured: _________________________________
Employer’s Name: ____________________________________________ Phone: ____________________
Employment Related Injury: □ Yes □ No     If Workers Comp, date of injury? ______________________

Secondary Insurance: ________________________________________ Effective Date: ________________
Subscriber ID: ______________________________________ Group No: ___________________________
Policyholder’s Name: __________________________________ DOB: ________ SSN: _______________

ASSIGNMENT AND RELEASE:
I authorize the release of any medical or other information necessary to process this claim. I hereby assign my insurance benefits to be
paid directly to the physician. I understand that I am financially responsible for any non-covered services (ie. Refractions and Routine
eye exams) and copayments. Also, any unpaid balances may be subject to collection and attorney’s fees, if assigned to a collection
agency, and is the responsibility of the guarantor.

SIGNED: ____________________________________________________ DATE: _____________________
                    PATIENT HISTORY FORM
TODAYS DATE: ________________

NAME: ___________________________________________________________

DATE OF BIRTH: _____/_____/_____    AGE: _________ RACE: __________

REFERRED BY: __________________FAMILY PHYSICIAN: _______________

PLEASE DESCRIBE THE REASON FOR YOUR VISIT TODAY:
________________________________________________________________
________________________________________________________________
_______________________________________________________

DO YOU SMOKE? _____________ DO YOU DRINK ALCOHOL? ______________

DO YOU HAVE A HISTORY OF: (PLEASE CIRCLE YES/NO)

GLAUCOMA                     YES      NO
FUCH’S DYSTROPHY             YES      NO
MACULAR DEGENERATION         YES      NO
CATARACTS                    YES      NO
DIABETES                     YES      NO     IF YES,   TYPE I OR TYPE II
ARTHRITIS                    YES      NO
BLINDNESS                    YES      NO
CANCER/TUMOR                 YES      NO     TYPE OF CANCER:
HIGH BLOOD PRESSURE          YES      NO
KIDNEY/BLADDER DISEASE       YES      NO
LUPUS                        YES      NO
STROKE/PALSY                 YES      NO
HEART DISEASE                YES      NO
THYROID DISEASE              YES      NO
HIGH CHOLESTEROL             YES      NO
ASTHMA/EMPHYSEMA             YES       NO
ANEMIA/BLOOD DISORDER        YES      NO
HIV                           YES     NO
STOMACH/INTESTINAL           YES      NO
DOES YOUR FAMILY HAVE A HISTORY OF: (PLEASE CIRCLE YES/NO)

GLAUCOMA                     YES     NO
FUCH’S DYSTROPHY             YES     NO
MACULAR DEGENERATION         YES     NO
CATARACTS                    YES     NO
DIABETES                     YES     NO       IF YES,   TYPE I OR TYPE II
ARTHRITIS                    YES     NO
BLINDNESS                    YES     NO
CANCER/TUMOR                 YES     NO       TYPE OF CANCER:
HIGH BLOOD PRESSURE          YES     NO
KIDNEY/BLADDER DISEASE       YES     NO
LUPUS                        YES     NO
STROKE/PALSY                 YES     NO
HEART DISEASE                YES     NO
THYROID DISEASE              YES     NO
HIGH CHOLESTEROL             YES     NO
ASTHMA/EMPHYSEMA             YES      NO
ANEMIA/BLOOD DISORDER        YES     NO
HIV                           YES    NO
STOMACH/INTESTINAL           YES     NO


WHAT IS YOUR OCCUPATION? _____________________________________

RETIRED/PAST OCCUPATION? _____________________________________

HOBBIES? ____________________________________________________


DO YOU WEAR GLASSES?      YES       NO   HOW LONG? ___________________
DO YOU WEAR CONTACTS?     YES       NO   HOW LONG? ___________________


ARE YOU EXPERIENCING ANY OF THE FOLLOWING OCULAR SYMPTOMS?
(CIRCLE THE ONES THAT APPLY)

PAIN                      ACHES                 DRYNESS
ITCHING                   BURNING               FLOATERS
LIGHT FLASHES             BLURRED VISION        LIGHT SENSITIVITY
GLARE AT NIGHT            HALOS                 FOREIGN BODY SENSATION
REDNESS                   DOUBLE VISION         MUCOUS DISCHARGE
TEARING                   TIRED EYES            SANDY/GRITTY FEELING
LOSS OF SIDE VISION       FLUCTUATING VISION
EYE HISTORY                               PLEASE DESCRIBE
   SURGERY         YES     NO
    INJURY         YES     NO
 CROSSED/LAZY      YES     NO
      EYE
    OTHER          YES     NO


LIST CURRENT MEDICATIONS:              LIST CURRENT EYE MEDICATIONS:
_______________ ________________      _________________ _________________
_______________ ________________      _________________ _________________
_______________ ________________      _________________ _________________
_______________ ________________
_______________ ________________       PAST SURGICAL HISTORY:
                                      ___________________________________
                                      ___________________________________
LIST ALL ALLERGIES:                   ___________________________________
_______________ ________________      ___________________________________
_______________ ________________      ___________________________________
_______________ ________________
_______________ ________________

DESCRIBE ANY OTHER SIGNIFICANT INFORMATION WE SHOULD KNOW BELOW:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________